- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.13 / $1,050.13 / $1,050.13
| Facility | | $1,050.13 | $1,050.13 | $1,050.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.01 / $1,710.26 / $2,940.71
| Facility | | $1,281.01 | $1,710.26 | $2,940.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,672.84 / $2,676.08 / $3,449.69
| Facility | | $1,672.84 | $2,676.08 | $3,449.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.72 / $1,891.45 / $2,175.52
| Professional | | $1,398.72 | $1,891.45 | $2,175.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $417.08 / $417.08 / $417.08
| Professional | AS | $417.08 | $417.08 | $417.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |